1st Journal Reading

Association of the Nonalcoholic Hepatic Steatosis and

Its Degrees With the Values of Liver Enzymes and
Homeostasis Model Assessment-Insulin Resistance
Index

Dr. Gina Ariani

Internal Medicine Department

Dr. M. Djamil Hospital, Padang
2016
 Research Article

Background
• Nonalcoholic fatty liver disease (NAFLD) is a
wide variety of factors including:
o Genetic.
o Environmental, and
o Metabolic
• Prevalence by ultrasonography (US) in
industrialized countries ranging from 12.2% to
40%.
 Research Article

Background
• An important factor related to the emergence
of nonalcoholic steatohepatitis (NASH) is the
presence of insulin resistance(IR).
• This is defined as a reduced biological
response to the actions of insulin, causing the
fat, muscle and liver tissues to become unable
to metabolize glucose and fatty acids, being
exacerbated by obesity and the intake of
dietary fats.
 Research Article

Background
• Association between IR and deposition of
triglycerid in the liver,  the homeostasis
model assessment-IR (HOMA-IR)
• The aim of this study was to investigate the
association between the degrees of
hepatic steatosis at abdominal ultrasound
and amounts of aminotransferases (AST
and ALT), GGT and HOMA-IR.
 Research Article

Material and Methods

• A prospective, descriptive survey type, with
analytical and quantitative approach
• Analyzed 800 patients who underwent the
examination for various clinical conditions, excluding
those with alcohol consumption > 40 g/day and
previous liver diseases, from July 2013 to July 2014.
 Research Article

Material and Methods

• Steatosis classified the degrees based on the
criteria of Saadeh et al (2002) :
o The degree 0 is the normal test.
o the grade 1 is characterized by the display of fine echoes
of the hepatic parenchyma with normal viewing of the
diaphragm and intrahepatics vessels,.
o grade 2 is characterized by diffuse increase in the fine
echoes with impaired view of intrahepatic vessels and
diaphragm, and
o Grade 3 is characterized with a significant increase in fine
echoes and impaired or absent visualization of
intrahepatic vessels.
 Research Article

Material and Methods

• In the statistical analysis, values were expressed as
median, first and third quartiles.
 Research Article

Result
• We diagnosed 233/800 (29.1%) patients by the US of
hepatic steatosis, 153 (65.7%) were female and 80
(34.3%) were male.
• Regarding degrees :
o Grade 1 : 119 (51.0%).
o Grade 2 : 94 (40.4%), and
o Grade 3 : 20 (8.6%).
• The median age of the patients ; grade 1 was 44.0
years (first quartile and third quartile were 37.0 and
51.0), grade 2 was 47.5 years (40.0 and 53.0) and
grade 3 was 45.5 (36.5 and 54.8), but did not vary
significantly (P > 0.05).
 Research Article

• The prevalence of alcoholic hepatic steatosis does

not vary depending on the region studied and the
diagnostic methods used.
• Eastern countries often have a lower prevalence
compared to the West, as the Western lifestyle is, in
itself, an important environmental risk factor.
 Research Article

Discussion
• Currently ultrasound criteria are mainly used to
evaluate the severity of hepatic steatosis.

• Bi et al (2014) found that patients with NAFLD with

advanced degrees had significantly increased
aminotransferase values, thus, there was strong
correlation between the levels of these enzymes
and NAFLD.
 Research Article

• ALT levels
increased as the
degree of
advanced
hepatic steatosis

Figure 1. ALT vs. hepatic

steatosis. ALT: alanine
transferase; P: significance.
 Research Article

Figure 2. AST vs. hepatic Figure 3. GGT vs. hepatic

steatosis. AST: aspartate steatosis. GGT: gamma-glutamyl
aminotransferase; transpeptidase;
P: significance. P: significance.
 Research Article

• AST, GGT, and HOMA-IR

levels increased as the
degree of advanced hepatic
steatosis (Fig. 2, 3, and 4),

Figure 4. HOMA-IR vs. hepatic steatosis.

HOMA-IR: homeostasis
model assessment-insulin resistance; P:
significance.
 Research Article

• The median AST, ALT, GGT and HOMA-IR index showed

statistically significant variation in the degree of hepatic
steatosis (P ≤ 0.05), as shown in Table.
• The AST showed a greater association with the severity of
steatosis (P = 0.0001) than the ALT (P = 0.001).
 Research Article

Discussion
• Tomizawa et al (2014) AST and ALT were
significantly higher in patients with NAFLD
compared to those without NAFLD (P = 0.0001).
• This study, which found a significant association of
AST and ALT levels with increased ultrasound
degrees of hepatic steatosis.
 Research Article

Discussion
• The increase in GGT can be found early in NAFLD;
however, Bi et al (2014) showed that ALT is a more
specific marker than GGT.

• The combination of US of the liver and HOMA-IR is a

sensitive and specific method not only to diagnose
steatosis, but also in the prediction of severity
 Research Article

Discussion
• Damiani et al (2011) have also shown a strong
relationship between IR measured by HOMA-IR and
hepatic fat.
• Fedchuk et al (2014) found a median HOMA-IR 3.3
(2.3 - 5.6) between patients with NAFLD.
• Thus, the study found that the coexistence of NAFLD
and elevated ALT are associated with IR and can be
useful for early detection of IR.
 Research Article

Conclusion

• ALT, AST, GGT and HOMA-IR are related to the

degrees of hepatic steatosis on ultrasound.
• It can help in the selection of patients for liver
histological evaluation.
 The question (PICO) of the study

Population/ Problem Patient with Non Alcoholic Hepatic Steatosis

Intervention No intervention given during the study

Comparison Level of ALT, AST, GGT and HOMA-IR with

severity of fatty liver

Outcome ALT, AST, GGT and HOMA-IR are related to

the degrees of hepatic steatosis on ultrasound
and can help in the selection of patients for
liver histological evaluation.
 CRITICAL APPRAISAL
DOES THIS REVIEW ADDRESS A CLEAR QUESTION?

1. Did the review address a clearly focused issue? Yes Can’t No

tell

Was there enough information on

 The population studied 

√

 The intervention given


 The outcomes considered

2. Did the authors look for the appropriate sort of papers?

The ‘best sort of studies’ would


 Address the review’s question

 Have an appropriate study design
ARE THE RESULT OF THIS REVIEW VALID?

3. Do you think the important, relevant studies were included? Yes Can’t tell No

Look for

 Which bibliographic database were used

 Follow up from reference lists 

 Personal contact with experts 

 Search for unpublished as well as published studies 

 Search for non English language studies 


4. Did the review’s authors do enough to assess the quality of the
included studies?

The authors need to consider the rigour of the studies they have 
identified. Lack of rigour may affect the studies results
5 . If the results of the review have been combined, was it
reasonable to do so?

Consider whether

 The results were similar from study to study 

 The result of all the included studies are clearly displayed
 What are the result>
6. What is the overall result of
the review?
Yes
Consider

 If you are clear about the

reviews ‘bottom line’ results
 What these are
ALT, AST, GGT and HOMA-IR
are related to the degrees of
hepatic steatosis on ultrasound
and can help in the selection of
patients for liver histological
evaluation.
Thank You